reflections of a family therapist

personality disorders

I find it interesting to notice that sometimes my conversations in therapy, with vastly different people and circumstances, seem to circle around themes on occasion. This week, I’ve noticed two topics that I am repeatedly seeing in session:

1. Men who have become “awake” to their own conflicts, problem behaviors and thinking and have made radical steps to be fuller, more peaceful people. Some have partners that are whole enough people themselves who rejoice in the change, and despite years of distance, hurt and resentments, fight along with their men to restore and renew their partnership. Others have partners who are too fragile, conflicted or hurt that the reversal appears like an “act” and feel the need to flee. Whatever the result, their is great Joy in the awakening, and it’s a pleasure to keep giving these new men feedback on their personal discoveries.

2. Narcissistic Personality Disorder. If there is a personality style that kills a marriage slowly and with deep pain, this is it. Whether the partner is male or female, the chronic lack of empathy on the part of the partner leaves the hurt, bewildered and worn-out one talking to me about how empty they feel when their partner, despite all evidence to the contrary, blames the spouse for all the pain, ignores the needs of their children, and never seems to connect with them. Worse still is the adult child who begins to recognize what growing up with a narcissistic mother or father has done to their sense of self, their confidence in relationships, or their ability to trust the empathy and care of another.

(I’m looking forward to the publication of the newest edition of the DSM-V. In it is a new model of personality disorders that I think will be helpful to the therapist as they come into regular contact with these persistent personality types.)

It’s been a long winter here in MN and the snow won’t quit. Once again, we will probably go from winter to summer in 24 hours. Hope that, wherever you are, you get all 4 of the earth’s seasons.

As the roar of reaction begins to quiet following the horror in Newtown, many media comments I have read express a demand for better “access to mental health services.”

I’m not sure what that means in this case.

The biggest gap in mental health care in our country, as I have come to know it, is in in-patient hospital care. After Congress passed laws in the 1980’s that down-sized state hospitals, hundreds of people were released from care. States and communities were expected to provide needed services, but in many places, such care never materialized. The numbers of homeless, mentally ill and/or addicted persons swelled, and state and federal dollars for the seriously and/or persistently mentally ill dwindled and has stayed low.

We have now have a chronic shortage of psychiatric hospital beds, and an even more critical shortage of child and adolescent psychiatrists. The cost of in-patient care is close to $1000 a day in some cities like Minneapolis. We have a shortage of psychiatrists because our medical system is controlled by the third party payer system of insurance companies, and they don’t pay psychiatrists commensurate to their 10 year + post-college medical training. Fewer medical students want a job with longer training and lower pay.

If the shooter in Connecticut wanted mental health care, there are plenty of master and doctorate level out-patient counselor/therapists in Fairfield County. Family physicians are often the first level of care for mental health, and would have been able to offer referrals for counselors and medication if needed. If anyone feared for his life or someone else, state laws around the country commonly allow for persons to be held in a locked hospital ward for up to 72 hours for evaluation.

But that is all for those whose mental health is clearly disturbed and dangerous. We’d like to believe that we can see the most dangerous among us coming from a mile away. The plain truth is that we often can’t.

Contemporary research into the minds of mass killers in America has shown that the majority are men who have had difficult lives and blame their pain on everyone else. They don’t have a sense of their own responsibility for their lives, and when pressed even harder by some large stressor like the loss of a job or an important relationship, plan a sweet revenge upon their oppressors. These are usually men with personality disorders, people whose characters have little concern for the well-being of others. These folks make up about 10% of the population and don’t seek mental health care. Or when they do, can fake their way through and get released without any improvement.

Stalin. Hitler. Mussolini. Pol Pot. Idi Amin. These men are mass murderers too. Do you think more mental health care would have solved the problem of human evil in them? No. We will always need to build a world that takes human sin seriously. That does what it can to control for access to weapons that kill quickly. That knows that evil doesn’t come at us through normal channels. That remembers that evil seeks power, and that power can overtake governments, too.

We weep with those whose lives have been shattered by evil in the form of a silent 20 year old killer. For their young lives lost. But also for all who, throughout human history, have died at the hands of evil persons. Evil does exist, and it exists not outside of us, in some kind of satanic underworld of the devil. Every evil I know of is born of a bent human mind, and the continuous will to wreck vengeance, power and control of others.

We can’t medicate, hospitalize, or counsel our way around human evil. Looking for relief from the mental health system is looking in the wrong direction.